Eli's Rehab Report

2011 PPS proposed rule cracks down on agencies' therapy use.

Are you hearing the wake-up call Medicare is sending you? Therapists will have to put a lot more time and effort into documentation and assessments under the prospective payment system proposed rule for next year.

In the rule published in the July 23 Federal Register, the Centers for Medicare & Medicaid Services proposes a laundry list of newly "clarified" requirements for home health therapy.

CMS is tackling therapy use and documentation because its analysis has shown that "in many cases therapy was being over-provided," the agency says in the rule. Despite a change in 2008 from a single 10-visit therapy threshold to three therapy thresholds of six, 14, and 20 visits with graduated steps in between, "some HHAs may be providing unnecessary therapy,"

CMS has found. (See "Senate Shines Searing Spotlight On Home Health Therapy" on pp. 69.)

Justification: The number of episodes with six to nine therapy visits increased 30 percent in 2008, which was good in CMS's view. But the number of episodes with 14 or more visits also increased 26 percent, the agency points out. Much of the increase is in areas with high fraud profiles, such as South Florida, CMS says.

Exceeding the six-visit therapy threshold will net episodes about $600 to $800, exceeding the 14-visit threshold will add an extra $300 to $400, and hitting the 20-visit mark brings $1,000 to $1,500 depending on early or late status and other case mix factors.

Overall case mix increased 4 percent from 2007 to 2008 with 38 percent of that increase due to therapy, CMS notes.

Reality: "It's no surprise to find CMS jumped on therapy," notes physical therapist Sparkle Sparks, a consultant with OASIS Answers. With the changes in threshold "it's not surprising they would see an increase." Many agencies really consider 14 visits the new threshold, Sparks observes.CMS has proposed the new therapy provisions to "clarify policies" to "assist HHAs" and "curb misuse," the rule says.

Background: Many agencies have questioned why CMS includes such a significant PPS reimbursement boost for therapy in the first place. The reason, CMS reveals in the rule, is it worried agencies would stint on high-priced therapy services without the reimbursement.

Reassessments May Change Your World

The biggest therapy change will be the reassessment requirement, expects Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.

Under the proposed rule, therapists -- not assistants -- will have to reassess the patient in person on the 13th and 19th visits. In other words, reassessments will occur before the patient hits the 14- or 20-visit therapy threshold for reimbursement.

In the reassessment, the therapist will need to make objective measurements and then gauge the patient's progress toward her therapy goals included in the plan of care, CMS explains. The therapist "must actively and personally participate in the functional assessment and measure the patient's progress," CMS dictates.

If the patient stops making progress toward her goals, the therapy won't be covered, CMS says. There is an exception if the patient is expected to make progress again, but the therapist must  thoroughly document the clinically supported reasons for that expectation in the record.

Fall out: The reassessment requirement will be a big shift for many agencies, Adams believes. "There are definitely some agencies that utilize physical therapists that use objective measures at the time of assessment and a smaller group that actually retest using objective measures through the treatment," Adams tells Eli. But "the majority of therapy services utilize a minimum number of objective measures at evaluation and never repeat those measures during the course of treatment." Currently there is no federal requirement for reassessments, Adams adds. Many states require them with a common timeframe of every 30 days, she notes. But the reassessments generally are not as thorough and don't require items like objective measurements, she says.

Bottom line: The mandate for reassessments and related documentation is going to add up to more time and effort for therapists, Adams forecasts.

Reassessment Times Too Specific

There also will be problems with the specific timeframe CMS proposes, expects physical therapist Cindy Krafft with consulting firm Fazzi Associates. Requiring reassessments is a good concept, she believes, but "tying it to one visit is a logistical nightmare."

For example: If a patient is receiving PT, occupational therapy, and speech therapy, the therapists would have to coordinate visit schedules closely to figure out who was responsible for the reassessment on the 13th or 19th visit.

Then if a visit got canceled, everyone would have to reshuffle schedules or re-coordinate to determine the visit number again. "CMS should consider whether it is practical to require a qualified therapist visit on specified days," the National Association for Home Care & Hospice urges. "The same result -- determination of patient progress and appropriateness of ongoing therapy -- also  could be achieved as effectively over a range of visits, such as 11-13 and 17-19," the trade group suggests.

Another nagging question is which objective measurements will fit CMS's criteria, Krafft says. The rule mentions using OASIS functional data or "commercially available therapy outcomes instruments."

On the other hand, therapists and agencies should be glad that CMS won't dictate exactly what measures to use, Krafft allows.

Note: The proposed rule is at http://edocket.access.gpo.

gov/2010/pdf/2010-17753.pdf. Comments are due Sept. 14. CMS discusses the therapy provisions on pp. 11-15 of the PDF file and the regulatory language is on pp. 45-46.

Bonus resource: Sign up for an Aug. 24 Eli-sponsored audioconference on the PPS proposed rule provisions with speaker Mark Sharp of BKD in Springfield, MO. Information is at www.audioeducator.com -- click on "Home Health" in the "Select Conference" box for the link.